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Based on observation, staff interviews, clinical record review, fire drill review, review of policies and procedures, it was determined the facility failed to protect and promote each patient's rights by failing to ensure every patient was informed of their rights and received the standardized notice "An Important Message from Medicare" within two (2) days of their admission (A117), failed to provide patients with the Ohio Department of Health Complaint hotline number (A118), failed to ensure every patient was provided the right to participate in the development and implementation of the plan of care (A130), failed to ensure the patient consented to care and treatment provided by the hospital, (A131), the facility failed to inform patients of the right to formulate advance directives (A132), the facility failed to ensure a safe environment for patients (A144), failed to investigate injuries of unknown origin (A144), and the facility failed to ensure all staff received education that specializes in the safe management of disruptive and assaultive behavior (CPI training) (A208). The cumulative effect of these systemic practices resulted in the facility's inability to ensure patients rights were promoted and protected. The census at time of the survey was 16.

Based on medical record review and staff interview, the facility failed to ensure every patient was informed of their rights and received the standardized notice "An Important Message from Medicare" within two (2) days of their admission. This affected one of seven current patients. (Patient #15) The facility failed to provide the correct contact information for the Quality Improvement Organization. This affected three of three patients whose medical records were reviewed for evidence of the Important Message from Medicare, Patients #3, #4 and #15 with the potential to affect all Medicare patients. The census at time of the survey was 16.

Findings include:

1. Review of Patient #15's medical record revealed admission to the facility on 06/05/16. On 06/07/16 Patient #15 was able to sign the Voluntary Admission Form and remained hospitalized as of 06/16/16.

The following admission documents remained unsigned as of 06/16/16: Treatment Consents and Authorizations, An Important Message from Medicare, Acknowledgement and Consent to Video Surveillance, Permission to Share Personal Health Information, and Certification of Receipt of Patient Rights Program Rules/Responsibilities, and Grievance Procedure.

Staff D, Staff E and Staff F were made aware of and confirmed these findings on 06/16/16 at 2:00 PM. Staff E stated the employee who did the intake should have completed the admission paperwork and that person is usually an RN (registered nurse).

2. Review of the An Important Message from Medicare notice was reviewed for Patients'
#3, #4 and #15. All three patients had Medicare listed as the primary insurance on their Registration Form. The notices contained two different telephone numbers for the Quality Improvement Organization (QIO): 1-800-589-7737 and 1-800-589-7337. Neither telephone number was the correct contact for the QIO of 1-855-408-8557.

Based on observations and staff interview, the facility failed to provide patients with the Ohio Department of Health Complaint hotline number. This could potentially affect all 16 patients in the facility.

Findings include:

Observations on 06/13/16 through 06/16/16 revealed the Ohio Department of Health Complaint Hotline number was not available in the facility. An interview with Staff F on 06/15/16 between 1:10 PM and 1:30 PM confirmed this number was not provided to patients.

Based on medical record review, policy review and staff interviews, the facility failed to ensure every patient was offered the right to participate in the development and implementation of their plan of care. This affected three patients of 14 medical records reviewed. (Patients #3, #4 and #15) The census at the time of the survey was 16.

Findings include:

Facility policy Treatment Planning Process (PC 137). Per policy, "The Treatment Plan is based upon an interdisciplinary assessment of each patient's needs, asses, strengths, and recovery goals. In the creation of the Treatment Plan, the interests and concerns of the patient, the family, significant others and case manager should reflect their full proactive participation in the treatment planning."

The policy also specified "Patients shall be prepared to attend and participate in the treatment planning process, as well as family members and significant others, as appropriate. Such participation shall be documented on the treatment plan" and "Patient's inability or refusal to participate in treatment planning ad the patient's reasons for such shall also be documented."

Under the heading Definitions and Responsibilities of the policy, "Patient and Significant Others: will be notified of team meetings, invited to attend and participate in the team to the fullest extent possible and to sign the completed plans."

Under the heading Procedures of the policy, "The patient is to participate in the treatment planning process. The patient's participation is essential to the recovery process and is to be directly involved in the treatment planning process with the following exceptions:

Patient requests not to be present, or requests to leave, the patient's presence is clinically contraindicated, the exceptions are to be clearly documented in the Treatment Team Planning Progress Note.

Also per policy, "The initial treatment plan shall be developed with active participation of the patient and implemented within 24 hours of admission through collaborative efforts by the multidisciplinary clinical treatment team" and "the plan shall be developed in accordance with the accepted standards of practice and be reviewed with the patient immediately upon completion and every seven (7) days thereafter."

1. Patient #3 was admitted to the facility on 03/29/16 and discharged on 04/15/16. A document entitled Comprehensive Treatment Plan Treatment Team Review dated 04/01/16 was reviewed. There was no documented evidence Patient #3 participated in this meeting. A second Comprehensive Treatment Plan Treatment Team Review took place on 04/04/16. There was no documented evidence Patient #3 participated in this meeting to discuss her progress towards discharge and ITP (interdisciplinary treatment plan) goals. The Treatment Plan was not reviewed again during the remainder of Patient #3's hospitalization.

Patient #3's medical record also lacked evidence of a Comprehensive Treatment Plan Problem List (ITP) form. The form was used to identify the patient's "problems" and included a section for the treatment team to document "In patient's own words: How will we know you are getting better?" There was no documented evidence Patient #3 participated in the development and implementation of her plan of care.

2. Patient #4 was admitted to the facility on 04/26/16 and discharged on 05/14/16. A document entitled Comprehensive Treatment Plan Treatment Team Review dated 04/29/16 was reviewed. There was no documented evidence Patient #4 or her guardian participated in this meeting. A second Comprehensive Treatment Plan Treatment Team Review took place on 05/05/16. There was no documented evidence Patient #4 or her guardian participated in this meeting to discuss her progress towards discharge and ITP (interdisciplinary treatment plan) goals.

A final meeting was held on 05/09/16 and there was no documented evidence Patient #4 or her guardian participated in this meeting to discuss her progress towards discharge and ITP (interdisciplinary treatment plan) goals.

Patient #4's medical record also lacked evidence of a Comprehensive Treatment Plan Problem List (ITP) form. There was no documented evidence Patient #4 or her guardian participated in the development and implementation of her plan of care.

3. Patient #15 was admitted to the facility on 06/05/16 and was a current patient as of 06/16/16. As of 06/16/16 there was no documented evidence of a Comprehensive Treatment Plan Treatment Team Review and no evidence of a Comprehensive Treatment Plan Problem List (ITP) form. There was no documented evidence Patient #15 participated in the development and implementation of her plan of care.

On 06/16/16 at 9:35 AM the facility's Treatment Team book was reviewed. The book reportedly contained all of the current patient Treatment Team Plans. The most current plans contained within the book were dated 05/29/16.

Review of that paperwork in the book revealed the following:

Two (2) Comprehensive Treatment Plan Treatment Team Review forms dated 05/19/16 without any patient identifying information including patient signature.

Five (5) Comprehensive Treatment Plan Treatment Team Review forms dated 05/23/16 without any patient identifying information including patient signature.

Eight (8) Comprehensive Treatment Plan Treatment Team Review forms dated 06/06/16 without any patient identifying information including patient signature.

11 Comprehensive Treatment Plan Treatment Team Review forms dated 06/09/16 without any patient identifying information including patient signature.

Staff D, Staff E and Staff F were made aware of and confirmed these findings on 06/16/16 at 2:00 PM. Staff E stated the Treatment Team meets twice a week, on Monday and Thursday, to discuss all of the patients. Approximately half of the patients are discussed on Monday and the other half are discussed on Thursday.

Staff E stated the Care Plan and Comprehensive Treatment Plan Treatment Team Review forms are brought to the meetings. Each patient is discussed and everyone signs to reveal they were present, including the patient. Staff E stated if the patient is unable or refuses to attend the meeting it should be documented on the sign in sheet.

Based on medical record review and interview, the facility failed to ensure the patient consented to care and treatment provided by the hospital. This affected one (Patient #1) of 14 records reviewed. The census at time of the survey was 16.

Findings include:

Review of the medical record for Patient #1 revealed the patient was admitted on 06/05/16. In the record was a form titled Application for Emergency Admission for Patient #1 on 06/05/16 at 7:31 AM. This form revealed Patient #1 was admitted to the facility by court order. Further review of the record revealed a Voluntary Admission Form with the signature of the patient. The date of the signature was blank and there was no witness to the signature on the Voluntary Admission Form. The Voluntary Admission Form included the statement that the patient was consenting "to the care and treatment which my doctor and the staff find necessary in my case. I reserve the right to ask questions about my treatment plan".

On 06/16/16 at 1:33 PM, Staff E confirmed the Application for Emergency Admission was good for 72 hours. Staff E revealed after 72 hours the facility would request the patient or guardian to sign the Voluntary Admission Form. Staff E confirmed the Voluntary Admission Form was not completed for Patient #1. Staff E also confirmed Patient #1 was a voluntary admission to the facility, after 72 hours for the emergency admission.

Based on medical record review and staff interview, the facility failed to inform one of seven current patients of her right to formulate advance directives, Patient #15. A total of 14 medical records were reviewed. The census at time of the survey was 16.

Findings include:

Patient #15 was admitted to the facility on 06/05/16. At the time of the record review on 06/16/16, the Advance Directive Acknowledgement had not been reviewed with Patient
#15.

Staff D, Staff E and Staff F were made aware of and confirmed this finding on 06/16/16 at 2:00 PM.

Based on review of facility policy, observations, and staff interviews, the facility failed to ensure a safe environment for patients in regard to disposal of full Sharps containers, an unlocked medical storage room, rubber gloves and their mounting racks, patient room windows that open, unsecured items at the nurses' station, and failure to follow-up and investigate injuries of unknown origin and failure to prevent a patient from leaving the facility unescorted when the fire alarm was sounded on the night shift. This could potentially affect all 16 patients in the facility.

Findings include:

Observations on 06/13/16 through 06/16/16 revealed the following:

The open nurse station, located by the great room, was observed with ink pens, pencils, paper clips, and a large potted plant on the countertop. Patients were observed throughout this area. The station was not consistently in attendance by staff.

Boxes of rubber gloves mounted in metal racks coated with plastic were observed inside each patient's room and inside the open and often unattended nursing station.

Patient room windows were observed with screens on each window. Interview and observation with Staff D and Staff E on 06/16/16 at 9:58 AM in Room 203 revealed the windows (2 in each room) open 6 inches in height. The windows were each at least 32 inches wide. Staff D measured the window opening at 6 inches in height, and stated the window frames contain a pin that keeps the windows from opening fully. One of the windows was unlocked upon entrance into the room. The locking mechanism was observed on the top of the lower window inside the room and was easily accessible. The patient rooms were located on the ground level of the facility next to a busy road. The windows were accessible from the grounds outside the facility wing where the unit is located.


1. Review of an incident report dated 06/02/16 revealed Patient #22 attempted elopement and the window screen was found laying outside on the ground. Both windows were open approximately eight inches in height. The screen was replaced, windows were closed and locked by staff.

Staff D stated it could not be confirmed which patient opened the window and pushed out the screen. According to the patient census list, Patient #22 was still a current patient.


2. Review of incident report documentation revealed two reports of bruises on patient #16 and #17. Patient #16 was discovered with a bruise during perineal care on 02/14/16. The incident report failed to list the location of the bruise. There was no investigation as to the cause of the bruise. This was confirmed with Staff D and E on 06/16/16 at 1:30 PM.

3. Patient #17 was discovered with a bruise on the left inner thigh on 05/20/16. There was no investigation by nursing as to the cause of the bruises on Patients #16 and #17. This was confirmed with Staff D and E on 06/16/16 at 1:30 PM.

An interview with Staff E on 06/16/16 at 4:00 PM confirmed the facility policy titled Incident Reporting/Reportable Incidents, effective 07/2015 and revised 11/2015, lacked evidence of a time frame for investigation of incidents.

During an interview with Staff D and Staff E on 06/16/16 between 1:10 PM and 1:30 PM, both employees were made aware of the aforementioned concerns in the environment and lack of investigation into injuries of unknown origin. When interviewed as to whether the rubber gloves and mounting racks and windows had been assessed in regard to a safe environment, Staff D replied that they were discussed prior to opening the facility and deemed to be acceptable in regard to patient safety. Staff D stated the metal glove racks would not support the weight of a person; however, the facility lacked documentation of these discussions and evidence regarding the assessment of the metal glove racks.




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4. Patient #14 was admitted to the facility on 03/01/16 with the diagnosis of schizophrenia. Review of a incident report on revealed on 03/09/16 at 12:50 AM Patient #14 eloped from the facility. A description of the event revealed the fire alarm was set off. Patient #14 was in the hallway. Staff observed Patient #14 going toward the exit door. Staff instructed patient not to continue but the patient was walking at a rapid pace. The patient opened the door and went approximately five to seven steps outside of the facility.

On 06/14/16 at 7:40 AM, Staff D confirmed Staff P put key in pull station and activated fire alarm. Review of personnel files revealed Staff P received a disciplinary action for putting patients in danger.


5. During the facility tour on 06/13/16 at 11:00 AM the Sharps container was observed in the medication room more than 2/3 full. Per Staff A the Sharps container needed to be disposed of due to being overfilled. An additional Sharps container greater than ¾ full was observed in the medical storage room.
Observation on 06/14/16 at approximately at 7:25 AM revealed Staff G entering and leaving the medical storage room at the nurses station without having to unlock the door. At 7:35 AM Staff A confirmed the door was unlocked. Staff A stated at this time the door does not need to be kept locked because patients should not be in the nurses station. This room was located inside the open nurses station and was not always attended by staff.
In an interview on 06/15/16 at approximately 2:15 PM Staff D, Staff E and Staff F were made aware of the above findings.









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Based on interview and review of personnel files, the facility failed to ensure all staff received education that specialized in the safe management of disruptive and assaultive behavior (CPI training). This involved 7 employees who provided direct care to patients. This could potentially affect all patients in the facility. The census at time of the survey was 16.

Findings include:

On 06/4/16 at 8:17 AM, an interview was conducted with Staff D regarding seven employees who had not received CPI training after being hired. Staff Z, Staff CC, Staff DD, Staff K, Staff EE, Staff FF, and Staff GG had been employed and working as direct care staff for greater than thirty days. Staff D confirmed the lack of this training for these employees.

On 06/15/16 an interview was conducted with Staff E and Staff M regarding CPI training. Staff M stated all direct care staff required this training, stating it should be completed per the green and white orientation sheet in the personnel file. A review of this orientation sheet revealed staff should receive CPI training within 30 days after hire.

Based on observations, staff interviews, medical record reviews, observations, review of personnel files, and review of policies and procedures, it was determined the facility failed to furnish and supervise nursing services by a registered nurse as the facility lacked documentation of orientation and a job description of the Director of Nursing (A386), failed ensure adequate staffing (A392), failed to ensure a registered nurse supervised and evaluated the nursing care of patients (A395), failed to ensure every patient had a nursing care plan and that it was reviewed and updated as needed (A396), failed to administer medications in accordance with physician's orders (A405), failed to ensure nursing staff followed the facility's procedure for taking a telephone order for a medication (A407)and failed to ensure nursing staff followed the facility's procedure for taking a telephone order (A410). The cumulative effect of these systemic practices resulted in the facility's inability to ensure the patients' nursing needs would be met.

Based on review of personnel files and interviews with staff, the facility lacked documentation of orientation and a job description of the Director of Nursing. The facility failed to provide oversight of nursing staff related to the administration of medications, medication errors, adverse drug reactions, care plans, telephone orders, nursing documentation including description and location of bruising, patient falls and patient elopement during fire alarm. This has the potential to affect all 16 patients in the facility.

Findings include:

Review of Staff E's personnel file revealed a lack of a job description and orientation to the position of Director of Nursing. According to the personnel file, this employee became the Director of Nursing on 02/08/16. There was no documentation of a job description or orientation to the role and job duties of this position.

On 06/15/16 at 2:30 PM an interview with Staff D, E, and H confirmed the lack of training for Staff E to the role of Director of Nursing. When interviewed as to whether the facility had an oversight plan in place to monitor nursing documentation and nursing activities, Staff E stated an inservice had been planned on 06/13/16 which included monitoring and audits of patient's medical records; however, confirmed there was currently no auditing to ensure appropriate nursing care of patients.

Interview with Staff D and E on 06/15/16 at 2:30 PM revealed these employees were unaware the medical record lacked documented location of the IM injection sites. Neither employee was aware of the Haldol and Ativan medications being given at the same time as the oral medications, or of the lack of documented behaviors for the use of the IM medications. Staff D, E and H confirmed they were not aware of the lack of injection site rotation and the lack of care plans or revision of care plans, the lack of description and location of bruises and lack of documentation regarding a patient elopement identified during survey.

Based on staff interviews and review of staffing schedules, the facility failed to ensure adequate numbers of staff to provide nursing care to all patients as needed. This involved one shift of staff and could potentially affect all patients in the facility. The census at time of the survey was 16.


Findings include:

A review of staffing schedules revealed two nurses staffed the facility between 9:23 PM on 05/28/16 and 7:00 AM on 05/29/16 with a census of ten patients during that time frame.

Further review of the working schedule beginning at 7:00 PM on 05/29/16 through 7:00 AM on 06/13/16 revealed three nursing staff on duty for 16 patients.

Interview with Staff D and Staff E on 06/16/16 at 1:30 PM confirmed the desired staffing ratio of one staff to four patients. Staff E stated an additional nursing staff member would have been preferable on 05/28/16 through 05/29/16. Both Staff D and Staff E stated staffing was challenging lately due to the termination of two employees.

Based on review of facility policy, observation, staff interviews and medical record reviews, the facility failed to ensure a registered nurse supervised and evaluated the nursing care of 9 of fourteen patients reviewed. (Patients #6, #7, #11, #14, #5, #16, #17, #4,and #9). This had the potential to affect all 16 patients receiving services from the facility.

Findings include:

1. Patient #6 was admitted to the facility on 04/03/16 with schizoaffective disorder (chronic mental disorder characterized with hallucinations and delusions). Review of the nursing admission assessment on 04/03/16 revealed the fall risk assessment score was five, which revealed the patient was at risk for falls. The Weekly Nursing Flowsheet revealed from 04/17/16 to 04/23/16 Patient #6 required assistance of one for activity. The flowsheet also revealed the patient had a bed alarm on.

Review of the nurses notes on 04/19/16 at 2:40 PM, revealed Patient #6 complained of dizziness and was unsteady on feet while walking to the bathroom. Orthostatic blood pressure revealed the patient's blood pressure was 82/60 in the lying position and 90/62 in the sitting position. The note revealed the patient was given Antivert medication for dizziness and the physician ordered to push fluids.

Further review of the nurses notes revealed on 04/21/16 at 7:30 PM a late entry was written for 04/20/16 at 6:30 PM. The note documented the patient was found on the floor in the bathroom, patient stated he/she slipped off the toilet in the bathroom, the patient heard a "popping" sound in his/her shoulder. The patient had normal range of motion with no grimacing or wincing and the certified nurse practitioner was notified (CNP).

Review of the mobile x ray report of the patient's bilateral shoulders and clavicle on 04/20/16 at 9:43 PM revealed there was evidence of a fracture of the right distal clavicle.

Review of the Physician's Assistant Note, dated 04/21/16, revealed Patient #6 had a fall in the bathroom when the patient was trying to seat self on the toilet. The patient sustained a fracture of distal right clavicle.

On 06/16/16 at 1:33 PM, Staff D confirmed the Nursing Progress Note on 04/20/16 at 11:45 PM (late entry) was not part of the medical record. Staff D revealed this note provided additional information about the fall. Patient #6's blood pressure was 84/60. Staff D revealed the patient was in bed and went to the bathroom by him/herself and staff found the patient on the floor. Staff D was not sure if the patient had a bed alarm on. Staff D also revealed the bathroom door alarm was to alert staff when patient enters the bathroom.

2. Review of the medical record for Patient #7 revealed the patient was admitted to the facility on 06/12/16 with the diagnosis of psychosis (mental disorder characterized by a disconnection from reality). Review of the form titled Safe Use of Side Rails, dated 06/12/16, revealed "no" was checked for the statements "Does patient use rails to adjust position in bed?" and "Can Patient get in/out of bed safely without any assistance?"

The form documented the interventions to be put in place was one upper side rail up at all times to access call light. The form had "no" checked for the use of both upper side rails.

Patient #7 was observed in bed with both upper side rails up on 06/15/16 at 8:00 AM and 8:30 AM. Staff J confirmed Patient #7 had both upper side rails up.

During an observation on 06/14/16 at approximately 12:00 PM Staff C was observed administering Novolin insulin 2 units per flexipen to Patient #7. Review of Staff C's documentation after the injection revealed Staff C failed to document the injection site on the MAR. Staff C confirmed the above finding and added the injection site to the MAR after the interview.

Review of the MAR for Patient #7 for 06/12/2016 through 06/14/16 revealed documentation of three subcutaneous insulin injections given with no documentation on the MAR of the injection site. Staff C added the site to the MAR after being made aware.


3. Review of the medical record for Patient #11 (82 year old) revealed the patient was admitted to the facility on 05/14/16 with diagnosis of psychosis. Review of the Nursing Progress Notes revealed, on 05/16/16 at 10:35 AM, Patient #11 was out to great room for breakfast and ate well. The note also documented the patient was "pleasant and cooperative with care and medications. Alert and oriented" times three (person, place and time).

Review of the medication administration record revealed at 05/16/16 at 4:05 PM Patient
#11 was administered an oral dose of lorazepam (Ativan), 0.5 milligrams (mg) ordered when necessary (PRN) for mild anxiety.

Review of the orders for Patient #11 revealed a telephone order on 05/16/16 with no time documented for Ativan 0.5 mg intramuscular (IM) now, times one. The order was from the certified nurse practitioner (CNP) given to a staff registered nurse (RN). There was no documentation in the nurses notes of the reason the oral dose of Ativan was given at 4:05 PM and the reason for the telephone order for Ativan IM now.

The next nurses notes was a late entry for 05/16/16. Review of the nurses notes revealed the when necessary Ativan was given per order at 7:00 PM. The note revealed the state tested nursing assistant took the patient's vital signs at 7:30 PM and they were within normal limits. The note documented at 8:00 PM the patient was resting peacefully and was not awakened. The note by the RN documented he/she went to assess the patient at 9:15 PM. The note revealed the patient was heavily sedated with short, shallow respirations of 14 per minute. Patient was nonresponsive to verbal commands, sternal rub, ataxia (loss of control of bodily movements)and hypotonia (low muscle strength). Vital signs were taken and the patient's blood pressure was 144/73, pulse was 92 per minute, respirations were 12 per minute and the patient's oxygen saturation was 89 percent with room air. The CNP was notified of the patient's condition. Emergency Medical Services were called and Patient #11 was transferred to the emergency department of a local hospital. The next nurses note documented Patient #11 arrived back at the facility on 05/17/16 at 2:00 AM after treatment for an accidental overdose.

Review of the Physician's Assistant's Note, dated 05/17/16, revealed Patient #11 was very lethargic after receiving an oral dose and IM dose of Ativan (benzodiazepine). The patient was treated with Romazicon (reverses drowsiness and sedation from benzodiazepines) in the emergency department of a local hospital.

Review of the Vital Signs Flow Sheet revealed vital signs were taken on Patient #11 on 05/16/16 twice with no times documented, 05/17/16 twice with no times documented, 05/18/16 once with no time documented, 05/19/16 twice with no times documented and 05/20/16 and 05/21/16 once with no time documented.

On 05/16/16 at 1:33 PM, Staff E confirmed the lack of documentation for the reason the as necessary dose of Ativan was administered.


4. Review of the medical record revealed Patient #14 was admitted to the facility on 03/01/16 with the diagnosis of schizophrenia. Review of an incident report dated 03/09/16 at 12:50 AM revealed Patient #14 eloped from the facility. A description of the event revealed the fire alarm was set off. Patient #14 was in the hallway at this time. Staff observed Patient #14 going toward the exit door. Staff instructed the patient not to continue but the patient was walking at a rapid pace. The patient opened the door and went approximately five to seven steps outside of the facility, before staff intervened and brought the patient back inside.

Review of the nurses notes for Patient #14 lacked evidence of documentation of the elopement. Record reveiw revealed a nursing note dated 03/08/16 at 10:30 PM that revealed the patient was in bed at the beginning of the shift with no negative behaviors observed. The next nursing note in the record was at 03/09/16 at 9:00 AM.

On 06/16/16 at 1:33 PM, Staff E confirmed the lack of documentation in the nursing notes that Patient #14 had eloped from the facility.


5. On 06/15/16 a review of Patient #5's medical record revealed the patient was admitted to the facility on 03/24/16 for delusional ideations and schizophrenia. According to the medical record review, medication administration record (MAR), and nursing notes, nursing staff failed to document the injection sites for intramuscular medications (IM) on 03/27/16 at 1:00 PM.

The patient had been receiving IM medications in the right and left shoulders between 03/24/16 and 03/31/16. On 04/18/16 a painful lump was discovered in the patient's left deltoid area. On 04/21/16 Physician's Assistant progress note revealed the following documentation: "The patient did have peculiar masses on the left shoulder, which were evaluated by a CT scan on 04/20/16. These findings are worrisome for a sinus tract/abscess formation in the subcutaneous tissue extending into the lateral deltoid muscle. Therefore, the patient will be studied further this afternoon and sent out for an MRI exam of the shoulder."

Nursing documentation and review of the MAR revealed Ativan, Benadryl, and Haldol IM medications ordered for agitation were given without documented reasons. The nursing documentation and MAR lacked evidence of documented behaviors requiring the use of these medications on the following dates and times:

On 03/31/16 at 9:00 PM the patient was given Haldol 5 mg by mouth and Haldol 5 mg IM at the same time. The physician's Haldol orders were documented to be given IM when the patient refused the by mouth medication (PO). However, the nursing documentation lacked evidence of refusal of the PO Haldol prior to giving them medication both orally and IM at 9:00 PM.

On 03/31/16 a late entry at 10:00 PM contained documentation the patient asked for medication for mood and admitted to anxiety and agitation. Although the medical record lacked documentation of severe agitation, at 9:00 PM that same date, the nurse administered injections of Ativan 2 mg, Benadryl 50 mg, and Haldol 5 mg, along with 5 mg of Haldol PO and Ativan 1 mg PO. The patient received a total of 10 mg of Haldol and 3 mg of Ativan at the same time.

Interview with Staff D and E on 06/15/16 at 2:30 PM revealed these employees were unaware the medical record lacked documented location of the IM injection sites. Neither employee was aware of the Haldol and Ativan medications being given at the same time as the oral medications, or of the lack of documented behaviors for the use of the IM medications, for Patient #5.

Staff E confirmed this in an interview on 06/15/16 at 2:30 PM with Staff D, Staff E, and Staff F.

6. Review of incident report documentation revealed patient #16 was discovered with a bruise during perineal care on 02/14/16. This patient's medical record nurses' notes lacked documentation of the description and location of the bruise.
This was confirmed with Staff D and E on 06/16/16 at 1:30 PM.

7. Review of incident report documentation revealed Patient #17 was discovered with a bruise on the left inner thigh on 05/20/16. The medical record nurses' notes lacked documentation of the size and description of the bruise.
This was confirmed with Staff D and E on 06/16/16 at 1:30 PM.

8. Facility policy Fall Risk Assessment/Post Fall Assessment (PC 120) was reviewed. Per policy, "the psychiatrist/internist will be contacted by the Charge Nurse to determine course of treatment after a patient has fallen."

Facility policy Care of Patient at Risk for Falls (PC 122) was reviewed. Per policy, "treatment team will develop a specific treatment plan with interventions once the patient is identified as high risk for falls" and "patients will be reassessed as needed; as their condition warrants. Reassessment shall be documented on the fall risk form; same as the fall risk assessment used on admission."

9. Patient #4 was admitted to the facility on 04/26/16. The Nursing Admission Assessment completed on 04/26/16 identified Patient #4 as a Fall Risk, with a risk score of 12.

Patient #4 then experienced a fall on 05/01/16 as documented in a Nursing Progress Note. The LPN (licensed practical nurse) who made the entry at 5:35 AM noted "patient reached back for wheelchair which patient unlocked and patient then went backwards hitting back of head on floor."

There was no documented evidence staff alerted the psychiatrist/internist, completed a post fall Fall Risk Assessment, updated the Care Plan or discussed the fall during Treatment Team.

Staff D, Staff E and Staff F were made aware of and confirmed these findings on 06/16/16 at 2:00 PM. During the interview Staff E stated the family, guardian, physician, DON and administrator should be notified a patient has experienced a fall. Staff E further stated a Fall Risk Re-Assessment and a Physical Therapy screening should be done. Staff D, E and F confirmed this was not done following Patient #4's fall on 05/01/16.

Review of the Facility policy titled Insulin Injection Procedure (effective 07/2015) was completed. The policy stated "to ensure rotation process, always document site of administration and dosage given either on the MAR (medication administration record) or Insulin Injection Site Document according to facility policy " .
Review of the Facility policy titled Intramuscular Medication Administration Procedure (effective 07/2015) was completed. The policy stated "document the injection on the MAR along with the site used (or use key on Mar, if applicable)".

10. During an observation on 06/14/2016 at approximately 10:55 AM Staff A was observed administering Haldol 5 mg IM (intramuscularly) to Patient #9. Review of Staff A's documentation after the observation revealed Staff A failed to document the injection site on the MAR. In an interview at the same time, Staff A confirmed the above finding.

Review of the MAR for Patient #9 for 06/09/2016 through 06/14/2016 revealed documentation of 12 IM injections given with no documentation on the MAR of the injection site.

In an interview on 06/14/2016 at approximately 12:05 PM Staff B stated she/he was unaware of the key on the MAR or of the Facility having an Insulin Injection Site Document. When interviewed how the nurses know to rotate injection sites, Staff B stated "I don't know. That is a good question."

Staff D, Staff E and Staff F were made aware of the above findings on 06/15/2016 at approximately 2:15 PM .








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Based on medical record review, policy review and staff interview, the facility failed to ensure every patient had a nursing care plan and that it was reviewed and updated as needed. This affected five of five patients whose medical records were reviewed for care plans. (Patients #3, #4 and #15, #6, and #14) A total of 14 medical records were reviewed. The census at time of the survey was 16.

Findings include:

Facility policy Plan of Care (PC 139) was reviewed. Per policy, "every patient shall have an individualized comprehensive plan of care" and "every patient's plan of care shall identify patient goals and associated objectives and interventions necessary to meet the identified goals."

The policy further stated "Goals and objectives will be re-evaluated and, as necessary, revised based on changes in the patient's condition, problems, needs and responses to care, treatment and services. If there is no appreciable change in the patient's condition, goals and objectives will be reevaluated and revised on a weekly basis."

1. Patient #3 was admitted to the facility on 03/29/16. The RN who completed the admission assessment identified the following nursing diagnoses to be integrated in to the plan of care: altered health maintenance, risk for injury/falls, ineffective coping, anxiety and sleep pattern disturbance.

Review of Patient #3's Care Plan, dated 04/07/16, revealed only the following nursing diagnoses were addressed: Manic Depression and Risk for Injury Potential for Falls.

There was no documented evidence the plan was reviewed at any time during the remainder of Patient #3's hospitalization and no evidence of the progress or lack of progress Patient #3 made toward the identified short and long term goals. Patient #3 was then discharged on 04/15/16.

2. Patient #4 was admitted to the facility on 04/26/16 and noted to have a history of diabetes and epilepsy with seizures. The RN who completed the admission assessment identified the following nursing diagnoses to be integrated in to the plan of care: impaired adjustment, noncompliance (not specified), risk for injury/falls, ineffective coping, anxiety and knowledge deficit.

Review of Patient #4's Care Plan, dated 04/26/16, revealed only the following nursing diagnoses were addressed: Risk for Injury Potential for Falls, Disruptive Behavior and Altered Thought Process.

The RN who initiated the Care Plan noted the next review was to occur on 05/01/16. There was no documented evidence the plan was reviewed at any time during the remainder of Patient #4's hospitalization and no evidence of the progress or lack of progress Patient #4 made toward the identified short and long term goals.

Patient #4 then experienced a fall on 05/01/16 as documented in a Nursing Progress Note. The fall was not addressed on the Care Plan. Patient #4 was then discharged on 05/14/16.

3. Patient #15 was admitted to the facility on 06/05/16 with a primary diagnosis of Acute Psychosis. Review of Patient #15's Care Plan, dated 06/05/16, revealed the following nursing diagnoses were addressed: Altered Thought Process, Risk for Injury Potential for Falls and Disruptive Behavior.

There was no documented evidence the plan was reviewed again and no evidence of the progress or lack of progress Patient #15 made toward the identified short and long term goals.

Staff D, Staff E and Staff F were made aware of and confirmed these findings on 06/16/16 at 2:00 PM. At that time Staff E stated every patient has a Care Plan that is reviewed at least once a week during Treatment Team.

4. Patient #6 was admitted to the facility on 04/03/16 with schizoaffective disorder. Review of the nursing admission assessment on 04/03/16 revealed the fall risk assessment documented Patient #6's score was five, which revealed the patient was at risk for falls.

Review of the nurses' notes revealed on 04/21/16 at 7:30 PM a late entry was written for 04/20/16 at 6:30 PM. The note documented the patient was found on the floor in the bathroom and the patient stated he/she slipped off the toilet in the bathroom.

Review of the mobile x ray report of bilateral shoulders and clavicle on 04/20/16 at 9:43 PM revealed there was evidence of a fracture of the right distal clavicle.

Review of the Fall Risk Reassessment, dated 04/20/16 at 7:15 PM revealed Patient #6's fall risk score was 13. The form revealed a score greater than 4 indicated the patient was to be placed on fall precautions. Review of the Risk for Injury care plan, dated 04/03/16, revealed the care plan was not reviewed after the fall on 04/20/16.

On 06/16/16 at 1:33 PM, Staff E confirmed the Risk for Injury care plan was not reviewed after the fall.

5. Review of the medical record revealed Patient #14 was admitted to the facility on 03/01/16 with the diagnosis of schizophrenia. Review of a Incident Report revealed on 03/09/16 Patient #14 eloped from the facility. Patient #14 was five to seven steps outside when staff intervened.

Review of the Comprehensive Treatment Plan Problem List for Patient #14 revealed the patient was at risk for falls, anxiety, depression and ineffective coping. Review of the care plans for Patient #14 revealed goals and interventions for these problems. Review of the Comprehensive Treatment Plan Problem List and care plan revealed elopement was not added as a new problem.

On 06/16/16 at 1:57 PM, Staff E confirmed the care plan for Patient #14 should have been updated after this incident.

Based on medical record review and staff interviews, the facility failed to administer medications in accordance with physicians' orders for one of 14 patients reviewed. (Patient #5). The census at time of the survey was 16.

Findings include:

Review of Patient #5's medical record and physician's orders revealed on 03/24/16 at 10:00 PM an order for Haldol 5 mg two times a day for schizophrenia, and on 03/25/16 for Ativan 2 mg IM (intramuscular) every four hours for agitation, Benadryl 50 mg IM every 4 hours, Haldol 5 mg IM every 4 hours for severe agitation. There was also a physician's order dated 03/28/16 for Haldol 5 mg every 4 hours prn (as needed) for severe agitation, give if refuses by mouth (PO).

A review of the medication administration record (MAR) for 03/31/16 revealed both the Haldol 5 mg PO and IM were given at 9:00 PM by the same nurse (Staff T). The nursing documentation and medical record lacked evidence of reason the Haldol IM was given at the same time as the PO medication, and lacked evidence of the patient refusing the PO medication. Staff E confirmed this in an interview on 06/15/16 at 2:30 PM with Staff D, Staff E, and Staff F.

Based on medical record review, review of policy and procedure and interview, the facility failed to ensure nursing staff followed the facility's procedure for taking a telephone order for a medication. This affected one (Patient #11) of 14 records reviewed. The census at time of the survey was 16.

Findings include:

Review of the policy and procedure for Telephone and Verbal Orders for Medication (Reference # PC 148.02..01.03), effective 7/2015, revealed all verbal and/or telephone orders for medications shall include the date and time the order is prescribed. The procedure also indicated the order was to be read back for frequency and/or instructions.

Review of the medical record for Patient #11 revealed the patient was admitted to the facility on 05/14/16 with diagnosis of psychosis. Review of the physician's orders for Patient #11 revealed a telephone order on 05/16/16 with no time for Ativan 0.5 mg intramuscular (IM) now, times one, from the certified nurse practitioner (CNP) given to a staff registered nurse (RN). There was no time on the telephone order and no indication the order was read back per policy.

On 06/16/16 at 1:45 PM, Staff E confirmed the telephone order for Ativan had not included the time the order was taken.

Based on medical record review and interview, the facility failed to review an adverse drug reaction. This affected one (Patient #11) of one record reviewed of a patient with an adverse drug reaction. The facility also failed to review medication administration errors in June 2016 which involved 2 patients (Patients #11 and Patient #18). The census at time of the survey was 16.

Findings include:

1. Review of the medication administration record documented at 05/16/16 at 4:05 PM revealed Patient #11 was administered an oral dose of Lorazepam (Ativan), 0.5 milligrams (mg) as needed for mild anxiety. Review of the physician's orders for Patient #11 revealed a telephone order on 05/16/16 with no time documented for Ativan 0.5 mg intramuscular (IM) now, times one, from the certified nurse practitioner (CNP) given to a staff registered nurse (RN). There was no documentation in the nurses' notes for the reason the oral dose of Ativan was given at 4:05 PM and the reason for the telephone order for Ativan IM now.

The next nurse's notes was a late entry for 05/16/16. Review of the nurses' notes revealed the when necessary Ativan was given per order at 7:00 PM. The note documented the state tested nursing assistants took the patient's vital signs at 7:30 PM and they were within normal limits. The note documented at 8:00 PM the patient was resting peacefully and was not awakened. The note by the RN documented he/she went to assess the patient at 9:15 PM. The note revealed the patient was heavily sedated with short, shallow respirations of 14 per minute. Patient was nonresponsive to verbal commands, sternal rub, ataxia (loss of control of bodily movements)and hypotonia (low muscle strength). Vital signs were taken and blood pressure was 144/73, pulse was 92 per minute, respirations 12 per minute and 89 percent oxygen saturation with room air. The CNP was notified of patient's condition. Emergency Medical Services were called and Patient #11 was transferred to the emergency department of a local hospital. The next nurse note documented Patient #11 arrived back at the facility on 05/17/16 at 2:00 AM after treatment for an accidental overdose.

Review of the Physician's Assistant's Note, dated 05/17/16, revealed Patient #11 was very lethargic after receiving an oral dose and IM dose of Ativan (benzodiazepine). The patient was treated with Romazicon (reverses drowsiness and sedation from benzodiazepines) in the emergency room.

On 05/16/16 at 1:30 PM, Staff E confirmed this adverse drug reaction was not reviewed.


2. On 06/16/16 a review was conducted of incident reports for June 2016 in regard to medication errors and follow-up/investigation for reasons the medication errors occurred. The reports titled Medication Variance Forms for June 2016 revealed medications were either omitted by nursing staff or given after the medication was discontinued. This affected discharged Patient #18.

According to the Medication Variance Forms dated 06/01/16 and 06/02/16, Patient #18 did not receive an antipsychotic medication from nursing Staff R as ordered at 9:00 PM (bedtime) on 05/30/16.

This patient also failed to receive another medication (Klonopin) from nursing Staff R at 9:00 PM on the same date. This medication was used for seizures and panic disorder.

An order for Lovenox (injectable medication used to treat deep vein thrombosis) was written on 05/30/16 at 12:45 PM and discontinued that same date by a nurse practitioner. On the physician's order sheet, a line was drawn through the medication and initialed by that employee. A medication variance form dated 06/02/16 contained documentation the medication was administered after it was discontinued by physician. Nurse gave the medication prior to checking new orders. The medication administration record contained documentation the medication was given by nursing Staff R on 05/31/16 and nursing Staff U on 06/01/16.

This was confirmed with Staff E on 06/16/16 at 4:00 PM. Staff E stated the nurse should conduct 24 hour checks on the medications to ensure orders are accurate in order to minimize or eliminate errors.





14226

Based on staff interviews and review of the fire drill documentation, the facility failed to meet life safety code requirements related to fire drills and transmission of the fire alarm signal and failed to test the release of the magnetic locks on the exit doors. This could potentially affect all 16 patients in the facility.

Findings include:

On 06/14/16 and 06/15/16, a review of the system event log revealed that on 03/09/16 at 00:46:56 a signal was received from the facility pull station located at the nursing station. The local fire department was notified less than one minute later for dispatch. The facility was notified and a partial clear was implemented at 00:50:12. Due to documented problems with locating an on call staff to reset the alarm, the alarm remained activated until 02:07:10 AM. The system was then documented as restored.

Interview of the assistant administrator on 06/15/16 regarding the incident confirmed an aide inserted a key into the locked pull station for an unknown reason. There was no fire. When the key was inserted the fire alarm was activated. The assistant administrator stated that due to the difficulty to reset the secured, covered pull stations, the pull stations are not activated for fire drills. Sounding of the alarm is coordinated with the adjoining skilled nursing facility. The assistant administrator confirmed that staff who activated the pull station for no apparent reason on 03/09/16 was terminated. When the facility fire alarm system is activated, the signal is received at a central monitoring location. A log of the received calls from the facility was requested and provided on 06/14/16 at 4:00 PM.

The assistant administrator was further interviewed regarding fire drill documentation in December 2015 which noted re-training was needed and that utilizing a pull station would be helpful. Information gathered from staff during interviews on 06/14/16 regarding fire procedures in the facility was shared with the assistant administrator. Some staff were not aware they had keys for the fire extinguisher cabinets, which keys were for the extinguisher cabinets or the pull station covers or they did not have the key with them. The administrator confirmed the information regarding the keys was provided on 03/14/16 and 03/15/16 during an in-service, however the facility has not activated a pull station for a fire drill.

The facility failed to test the release of the magnetic locks on exit doors.

Based on medical record review and interview, the facility failed to reassess the patient's discharge plan after an elopement from the facility. This affected one (Patient #14) of 14 records reviewed. The facility's current census was 16.

Findings include:

Review of the medical record revealed Patient #14 was admitted to the facility on 03/01/16 with the diagnosis of schizophrenia. Review of a incident report revealed on 03/09/16 at 12:50 AM Patient #14 eloped from the facility. The patient opened the door and went approximately five to seven steps outside of the facility, before staff intervened.

Review of the Discharge Planning Assessment/Evaluation form Social Service Department, dated 03/11/16, revealed no evidence Patient #14 had eloped the facility.

On 06/16/16 at 10:30 AM, Staff V confirmed he/she was not aware that Patient #14 had eloped from the facility. Staff V revealed he/she was in charge of discharge planning and elopement risk was a consideration to ensure patients are discharged to an appropriate setting for safety.